Treating and Preventing Adolescent Mental Health Disorders: Treating and Preventing Adolescent Mental Health Disorders

Book Title: Treating and Preventing Adolescent Mental Health Disorders > pp. [260]-[264]

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Treating and Preventing Adolescent Mental Health Disorders

Print ISBN 9780195173642, 2005
pp. [260]-[264]

Table 13.1 DSM-IV Diagnostic Criteria for Anorexia Nervosa

A.	Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of the expected)
B.	Intense fear of gaining weight or becoming fat, even though underweight
C.	Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight
D.	In postmenarcheal females, amenorrhea, i.e., absence of at least three consecutive menstrual cycles (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

Specify Type

Restricting typeDuring the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Binge eating/purging typeDuring the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

patients to control, thus inability might be more accurate than refusal.

Many individuals with anorexia nervosa acknowledge the core phenomenon described in Criterion B, an intense fear of gaining weight or becoming fat. However, younger individuals and individuals who are not motivated for treatment sometimes deny that they fear gaining weight, despite engaging in behaviors that strongly suggest an intense fear of fatness. It is possible that this criterion might be better worded to capture the characteristic behaviors rather than focusing on a psychological parameter. Criterion C is complex, as it describes three rather distinct phe nomena in an attempt to define the core psychological features of anorexia nervosa. The disturbance in the experience of body weight or shape is observable from statements of feeling fat or of perceiving specific parts of the body as being too large, even when the person is emaciated. Individuals with anorexia nervosa are remarkably successful at remaining underweight, thereby deriving a feeling of accomplishment by evaluating themselves in terms of their thinness. An admission of the seriousness of low body weight would imply an acknowledgment of the necessity of changing behavior and gaining weight, which are overwhelming and terrifying notions.

The final criterion for the diagnosis of anorexia nervosa, amenorrhea, remains controversial. The physiological implications of the amenorrhea are not entirely clear; some investigators have suggested that its presence might be indicative of a primary disturbance of hypothalamic function (Pirke, Fichter, Lund, & Doerr, 1979; Russell, 1969), whereas others maintain that amenorrhea is merely a reflection of dieting and weight loss (Katz, Boyar, Roffwang, Hellman, & Weiner, 1978). Several reports have suggested that the characteristics of individuals who meet all diagnostic criteria for anorexia nervosa except amenorrhea do not differ from those of individuals who meet all the criteria (Cachelin & Maher, 1998; Garfinkel et al., 1996). These observations, in addition to the occasional difficulty of obtaining an accurate history of menstrual patterns from patients, suggest that amenorrhea may be a less useful criterion for anorexia nervosa.

The DSM-IV suggests that individuals with anorexia nervosa be further described as belonging to one of two mutually exclusive subtypes, the restricting type (AN-R) and the binge eating/purging type (AN-B/P). These subtypes were included in the DSM-IV criteria for anorexia nervosa because of data indicating that in comparison with AN-R patients, AN-B/P patients have a higher frequency of impulsive behaviors such as suicide attempts, self-mutilation, stealing, and alcohol and substance abuse (Casper, Eckert, Halmi, Goldberg, & Davis, 1980; Garfinkel, Moldofsky, & Garner, 1980). In addition, the binge eating and purging behaviors of individuals with AN-B/P predispose these individuals to medical

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problems less frequently associated with AN-R (Halmi, 2002).

Comparison of Anorexia Nervosa in Adolescents and Adults

The DSM-IV system of classification does not suggest that a different set of criteria be employed for adolescents with anorexia nervosa. It is of interest to note that the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980) placed the anorexia nervosa criteria in the section on child and adolescent disorders, which reflects the fact that most cases of anorexia nervosa have their onset during adolescent years. Several studies provide information on whether there are substantial differences in the clinical characteristics of adolescent and older individuals with anorexia nervosa.

Halmi, Caspar, Eckert, Goldberg, and Davis (1979) examined correlations between a variety of clinical characteristics and age of onset of anorexia nervosa. Younger patients were hospitalized somewhat sooner than older patients after the onset of their illness, and older age of onset was associated with a greater weight loss from normal. Most of the typical anorectic behaviors and attitudes occurred with a greater frequency in patients with a younger age of onset. In general, however, there were very few significant age-related correlations. Heebink, Sunday, and Halmi (1995) compared clinical characteristics of four age groups of female inpatients on an eating disorders unit: early adolescence (ages 12 through 13), middle adolescence (ages 14, 15, and 16), late adolescence (ages 17, 18, and 19), and adult (age 20 and older). Few psychological differences were observed between the adults and the adolescents. Onset of anorexia nervosa before age 14 and primary amenorrhea were associated with the greatest maturity fears. Among AN-R patients, adolescents aged 17 through 19 had the highest drive for thinness, and the lowest levels of depression and anxiety were seen in patients younger than age 14. These data suggest that eating disorder symptomatology is fairly consistent in presentation over the life cycle.

Fisher, Schneider, Burns, Symons, and Mandel (2001) compared patients between the ages of 9 and 19 years with patients aged 20 to 46. On most variables, there were no significant differences between the adolescents and adults. The adults were more likely to have a history of binge eating, laxative abuse, diuretic and ipecac use, and prior use of psychiatric medications. The adolescents were more likely than adults to have a diagnosis of EDNOS, and the adolescents had a lower global severity score, greater denial, and less desire for help. Although the study showed some age-related differences between adolescents and adults, changes to the DSM-IV diagnostic criteria for the adolescent population were not recommended.

Additionally, in a study comparing the general psychopathology of early-onset anorexia nervosa to that defined as classic adolescent-onset anorexia nervosa (Cooper, Watkins, Bryant-Waugh, & Lask, 2002), the specific eating disorder psychopathology and general psychopathology in the early onset anorexia nervosa group were very similar to those of the late-onset anorexia nervosa sample. Thus, there is little evidence to suggest that the core clinical characteristics of adolescents with anorexia nervosa differ substantially from those of adults, and it does not appear necessary to modify the diagnostic criteria for anorexia nervosa for use with adolescents.

Diagnostic Criteria for Bulimia Nervosa

The DSM-IV diagnostic criteria for bulimia nervosa are listed in Table 13.2. As with anorexia nervosa, the diagnostic criteria for bulimia nervosa are at times difficult to interpret. Criterion A, which provides a definition of a binge eating episode, addresses amount (“larger than most people would eat”), duration (“in a discrete period of time”), and psychological state (“a sense of a lack of control”). The relative importance of these elements and the definitions offered are open to interpretation. For example, many patients with bulimia nervosa state that they are binge eating when they eat amounts of food that are not larger than what most people eat and believe that the sense of loss of control is more important than the amount ingested.

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Table 13.2 DSM-IV Diagnostic Criteria for Bulimia Nervosa

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

i.	Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances
ii.	A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise

Binge eating and inappropriate compensatory behaviors both occur on average at least twice a week for 3 months.

Self-evaluation is unduly influenced by body shape and weight.

The disturbance does not occur exclusively during episodes of anorexia nervosa.

Criterion B, which describes recurrent and inappropriate behaviors, includes some behaviors that are easily characterized (self-induced vomiting) and others that are open to interpretation (for example, what is “misuse” of laxatives and diuretics?). Particularly problematic is the question of what constitutes excessive exercise.

Criterion C requires that the binge eating and inappropriate compensatory behaviors occur on average at least twice a week for 3 months, but studies suggest that individuals with somewhat lower reported frequencies of binge eating closely resemble individuals who meet Criterion C. Criterion D, that self-evaluation is unduly influenced by body shape and weight, is part of the anorexia nervosa criteria as well, and attempts to capture an important psychopathological variable. But the line between “undue influence” and normative overconcern with body shape and weight among female adolescents is uncertain.

Evaluation of DSM-IV Classification for Adolescents with Eating Disorders

One indicator of the utility of the diagnostic criteria for eating disorders is the degree to which they capture the signs and symptoms reported by patients who present for assessment because of distress about their symptoms or because of medical, psychological, or social impairment resulting from these problems. Most patients treated in clinical settings do not meet full criteria for either anorexia nervosa or bulimia nervosa but instead must be grouped into the EDNOS category, which includes some specific examples of eating patterns that do not meet the full criteria for anorexia nervosa or bulimia nervosa but which remains for the most part poorly characterized.

For example, in data collected as part of an eating disorder database system involving five clinical centers (Neuropsychiatric Research Institute/University of North Dakota; University of South Florida; University of Toledo; Ohio State University; University of Chicago) and including a total of 704 patients, the percentage of subjects meeting full criteria for bulimia nervosa ranged from 12% to 20% and for subjects meeting full criteria for anorexia nervosa from 3% to 17%. The percentage of those diagnosed with EDNOS ranged from 49% to 71%. Of the adolescent patients in this database (N = 163), 86 (53%) received a diagnosis of EDNOS. This finding is reflected in other literature as well. Fisher and colleagues (2001) compared adolescents and young adults at presentation to an eating disorder program, and found that the likelihood of EDNOS was high in both populations but was highest among the adolescents. Others have discussed the high rate of EDNOS in adolescents and the inadequacy of the DSM criteria as well (Brewerton, 2002; Dancyger & Garfinkel, 1995; Eliot & Baker, 2001; Engelsen, 1999; Fisher et al., 1995; Muscari, 2002; Nicholls, Chater, & Lask, 2000).

Factors that appear to be risk factors for the later development of eating disorders, which are discussed in detail in Chapter 15, are common among adolescent girls, and some are so common as to be considered normative. A question relevant to both devising prevention efforts and

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considering the most appropriate diagnostic criteria is where to draw the line, to decide that a clinically significant eating problem has developed. Are cognitive concerns sufficient, are early behavioral symptoms necessary, or does a well-established pattern of such behaviors need to emerge? Prior research has shown that the altering of severity criteria would result in substantial changes in base rates of bulimia nervosa (Thaw, Williamson, & Martin, 2001).

Alternatives to DSM-IV Classification

As described above, the DSM-IV system fails to provide useful categories for a substantial number of individuals with significant eating disorder symptoms. A possible alternative to the DSM-IV categories for an adolescent population is provided by the Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version (Wolraich, Felice, & Drotar, 1996), developed by the American Academy of Pediatrics. This manual provides a broader classification scheme and includes a hierarchy of clinical presentations that do not reach full DSM-IV diagnostic criteria but that nonetheless deserve clinical attention. “Variations” represent minor dysfunctional symptoms related to eating or body image and “problems” reflect more serious disturbances. The utility of this system has received little empirical examination. The clinical characteristics of individuals in these categories are unknown, as is the prevalence of these characteristics. In addition, it is not known how often or whether DSM-PC variations or problems advance to become DSM-IV full syndromes. Nonetheless, this system provides a potentially useful method for defining a wide range of important eating problems among adolescents.

In an attempt to describe the wide range of eating problems seen among children, the Great Ormond Street criteria were developed (Lask & Bryant-Waugh, 2000). These criteria include determined weight loss, abnormal cognitions about body weight and shape, and morbid preoccupation with body weight and shape for the diagnosis of anorexia nervosa. The bulimia nervosa criteria include recurrent binges and purges, a sense of lack of control, and morbid preoccu pation with shape and weight. A unique feature of these criteria is the inclusion of specific criteria for additional disorders, such as food avoidance emotional disorder, selective eating, functional dysphagia, and pervasive refusal syndrome. The utility of the Great Ormond Street criteria is just beginning to be explored empirically.

Summary

The DSM-IV criteria for anorexia nervosa and bulimia nervosa are widely used and are useful in recognizing and describing both adolescents and adults with severe disturbances of eating behavior. However, it is not completely clear how several of the criteria for both anorexia nervosa and bulimia nervosa should be interpreted. The criterion requiring amenorrhea for the diagnosis of anorexia nervosa is particularly problematic and may need to be eliminated. The available literature strongly suggests that the criteria sets provided by DSM-IV fail to describe many adolescents and adults with clinically significant eating problems. Indeed, EDNOS is the most common diagnosis assigned in eating disorder programs. Thus, the DSM-IV criteria may need to be broadened, and other categories for less severely affected individuals may need to be added.

DEMOGRAPHICS AND PREVALENCE OF EATING DISORDERS

Despite exponential growth in eating disorders research the past few decades (Theander, 2002), epidemiological research has lagged behind research in other areas, such as studies of the clinical presentation of eating disorders and research on treatment interventions. Although the symptoms of eating disorders are known to originate primarily during adolescence, epidemiological studies have focused principally on adult populations. Consequently, data on the prevalence and distribution of anorexia nervosa and bulimia nervosa among adolescents are quite limited.

Even among adults, knowledge about the number of individuals having an eating dis

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order or about particular vulnerability to developing anorexia nervosa, bulimia nervosa, or their variants (for review, see Striegel-Moore & Cachelin, 2001) is limited. For example, only one study in the United States, conducted about 25 years ago, has provided prevalence data for eating disorders based on a nationally representative sample (Robins & Regier, 1991). Rates of bulimia nervosa were not documented, as this disorder had not yet been introduced into the psychiatric nomenclature.

Experts have concluded that eating disorders occur in approximately 1% (anorexia nervosa) to 3% (bulimia nervosa) of women, and prevalence rates among men are approximately one tenth of those observed in women (for review, see Hoek, 2002). Large samples are needed to describe even the most easily identified epidemiological parameters such as gender or ethnicity, and as the review by Hoek, van Hoeken, and Katzman (2003) illustrates, even in samples exceeding 1,000 girls, some studies have not identified a single girl with past or current anorexia nervosa (e.g., Johnson-Sabine, Wood, Patton, Mann, & Wakeling, 1988). Because of the rather preliminary stage of epidemiological research among adolescent samples, studies based on relatively small or select samples or only on self-report are not reviewed in this chapter.

Fifteen recent studies (summarized in Tables 13.3 and 13.4) have provided interview-based information about the prevalence of anorexia nervosa and bulimia nervosa as defined by DSM-III (1980) and DSM-IV criteria. In some instances, the prevalence of partial syndrome eating disorders in community-based samples was also determined. Some studies recruited not only adolescents but also younger children or adults; these studies are also reviewed (e.g., Newman et al., 1996).

Prevalence Studies of Anorexia Nervosa and Bulimia Nervosa: Methodological Considerations

Ideally, epidemiological studies recruit adequately large, representative population samples and provide detailed information about the sampling frame, recruitment procedures, and partic ipation rates. Because eating disorders are fairly uncommon in adults (Hoek, 2002), sample sizes of several thousand (for studies focused on girls) to tens of thousands of participants (for studies focusing also on eating disorders in boys) are needed for stable estimates of eating disorders. Most studies reviewed in this chapter had fewer than 1,000 participants and only one study had over 10,000. Regrettably, the latter did not report detailed information about eating disorder cases, leaving unknown the specific disorders found (anorexia nervosa or bulimia nervosa) or the gender of those affected by an eating disorder (Emerson, 2003).

Most studies were conducted in European countries (ranging from Norway to Italy) and included populations representing Western industrialized nations. Five studies were conducted in the United States (Graber, Tyrka, & Brooks-Gunn, 2003; Johnson, Cohen, Kasen, & Brook, 2002; Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993; McKnight Investigators, 2003; Whitaker et al., 1990) and one was done in New Zealand (Newman et al., 1996). A considerable variety of sampling frames was used (ranging from the recruitment of girls at a single school, to the use of sophisticated stratification schemes, to the recruitment of an entire birth cohort in a particular county). Only two studies recruited national probability samples of children in a particular age range (Emerson, 2003: Great Britain; Verhulst, van der Ende, Ferdinand, & Kasius, 1997: the Netherlands). Unfortunately, although they included both girls and boys, neither study reported gender-specific eating disorder rates. None of the studies examined ethnic differences in the prevalence of eating disorders.

In nine studies (summarized in Table 13.3) a two-stage case-finding approach was used: a questionnaire was given to the entire sample and was followed by a diagnostic interview of those individuals whose responses to the initial screening suggested the presence of an eating disorder. In some studies, a random subset of those participants who screened negatively for an eating disorder were also interviewed. The two-stage screening approach permits a relatively cost-effective assessment of large samples through use of an inexpensive survey method first, reserving the expensive interview method for

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doi:10.1093/9780195173642.003.0014